Compliance with Medication Recommendations
© 2005 Prime Health Consultants, Inc.
Compliance is defined as “the extent to which a person’s behavior coincides with medical or health advice.” Despite the importance of the medication in treatment, disease prevention, and health promotion, compliance rates range from 11% to 93%. The authors reviewed pediatric medication compliance literature based on Medline searches of: medication compliance, patient compliance, patient dropouts, or treatment refusal combined with 45 other terms including drug therapy and specific formulations or methods of drug delivery. Additionally, data were excerpted from an AAP Periodic Survey on primary care pediatricians’ views on patient compliance with completing prescriptions for acute and chronic illness. The authors noted a caveat regarding compliance data reliability: parental reports of compliance have been shown to be markedly overrated (eg, in one study, mothers reported 60% compliance with obtaining prescribed refills, compared to only 12% according to pharmacy records).
The review yielded a number of principles pertaining to barriers to good medical regimen adherence. Limits on the time the physician can spend with each patient and family to negotiate a best-fit medication and discuss their ability to comply with the prescribed regimen represents a significant barrier. Lack of continuity of physician-patient interaction, particularly between and within multi-personnel office settings, is a strong predictor of poor compliance. Patient and family characteristics constitute additional sets of factors influencing compliance: the patient’s and family’s ability to understand the importance of following the prescribed treatment is an important element. Factors affecting understanding include health literacy, education, and culture. Patient/family knowledge, information, and misinformation or perspectives from outside sources (including the Internet) influence compliance, as can psychological function (eg, psychopathology). Such preexisting or emerging problems necessarily require attention in order to enhance compliance.
Practice setting characteristics and specific physician behaviors can influence compliance. Parents are more likely to be actively involved in the communication process if they are not distracted by restless children, their own time constraints, and annoyance over long waits. Enhanced communication skills have been known to shorten visit duration, improve patient adherence, and decrease the need for follow-up care.
Medication factors (eg, duration, schedule, formulation, palatability, cost, and adverse effects) were clearly associated with compliance. Longer duration of the medication regimen and increased complexity of the medication schedule represented risk factors to adherence, with mid-day dosings being particularly problematic. Personal preferences and aversions became evident in relation to forms of medication and palatability. Children expressed preferences for one form over another (eg, sprinkles vs syrup) whereas parents preferred oral liquid to solid forms (eg, powder, tablets, capsules). Medication cost for the uninsured or under-insured constituted an additional burden leading to compromised compliance. Cost also drove drug formulary decisions that restricted access to some useful medications that were more palatable and/or facilitated the dosing schedule. Finally, adverse effects from medications decreased compliance.
The authors outlined a set of General Principles to Enhance Medication Compliance that include: (1) improving communication between physician and patient/family, (2) modifying or negotiating regimens, (3) emphasizing patient self-management of disease or illness, (4) using the simplest and most effective regimen available, and (5) using technology and devices to facilitate compliance. The authors stated the overriding issue for improved compliance is developing a one-on-one relationship between “1 doctor and 1 patient.”
First Editor’s Comment: The term compliance is often used interchangeably with adherence, as it has been in this paper. However, compliance entails obedience to a directive from a physician (eg, “take this medication 3 times a day”), whereas adherence implies that the patient and family are active collaborators in the treatment process. The WHO defines adherence as “the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.”1
The average adherence to medication recommendations is approximately 50% in the pediatric population.2 Despite intuitive expectations, adherence can falter even in life-threatening conditions such as type 1 diabetes (T1DM) and congenital adrenal hyperplasia. Winnick et al emphasized the critical importance of the one-on-one relationship between physician and patient as the key to improving adherence. Improved delivery systems (eg, pumps, transdermal patches, etc.) alone are unlikely to eliminate adherence problems. For example, a good collaborative relationship associated with clear communication would facilitate prompt discovery that the adolescent with uncontrolled T1DM has “broken” insulin pumps because he is embarrassed that his peers can see the device. Another example would be the young adult male with gonadotropin deficiency who fails to adhere to recommendations because the testosterone replacement dose is inadequate for normal erectile function. There is typically an explanation for poor adherence, but the remedy presupposes strong lines of communication between the physician and the patient and the family. The cost is time—the time to develop and maintain a relationship. While technological advances can facilitate adherence, when problems emerge, they cannot be confused with the solution.
Finally, the authors’ recommendation to “emphasize patient self-management of disease or illness” should be interpreted cautiously. In the pediatric context, one needs to know who assumes responsibility for various aspects of medical care or how that responsibility is shared within the family.
David E. Sandberg, PhD
Second Editor’s Comment: Coincidentally, Osterberg and Blaschke3 published a review article, “Adherence to Medication” which denotes the importance of this issue across disciplines. As C. Everett Koop said, “Drugs don’t work in patients who don’t take them.” The problem is of particular importance to pediatric endocrinologists who treat patients with chronic conditions requiring long-term therapy, complex regimens, and frequent medication changes. Furthermore, patients are often asymptomatic and cannot care for themselves. These patient characteristics are typical of poor compliance and/or adherence to treatment. Lack of response to medication, missed appointments, presence of psychological problems, and/or cognitive impairment of the patient or caregiver may be indicators of poor adherence. High medication costs and third-party payor requirements including high co-payments and frequent refills compound the problem. These barriers are important and add to the time required to obtain medications. Poor adherence contributes to worsening of disease, increased costs of care, and even death. New cost-efficient technologies that facilitate treatment adherence are needed to aid physicians and patients in meeting the goals of therapy.
Fima Lifshitz, MD
References - (linked to 
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- World Health Organization. http://www.who.int/chronic_conditions/adherencereport/en/. Accessed November 2, 2005.
- Matsui DM. Pediatr Clin North Am. 1997; 44:1-14.
- Osterberg L, Blaschke T. N Engl J Med. 2005;353:487-497.